Breast Cancer in Hispanic Women: Critique of Research

Purpose/Problem

The research article of Hall and colleagues (2007) entitled “Effects of a culturally sensitive education program on the breast cancer knowledge and beliefs of Hispanic women” described the effectiveness of a particular breast cancer awareness effort on the beliefs and activities of women belonging to the ethnic group of Hispanics.

Literature Review

The research was conducted on this particular ethnic group because it has been determined that Hispanics are the fastest and most significant minority group in the United States. Demographic analysis of the total current population of the United States showed that approximately 13% of the society is Hispanic in origin, amounting to around 40 million people. Projection estimates show that within 3 years, this number will increase by 16%. Most of the Hispanic individuals live in states in the west and southern coasts of the United States. Among the American states, Arkansas has been identified to carry the highest number of Hispanics, amounting to 127,000 individuals, representing 4% of the total population of the state. The recent immigration of Hispanics into the United States has thus changed the demographics of a number of states in the United States.

The research on breast cancer awareness among Hispanic women originated from the observation that individuals of different ethnic groups have different survival outcomes for particular medical disorders. For example, the probability of death due to cancer was observed to be higher among Hispanic women, as compared to Caucasian females. Another observation is that cancer of often diagnosed at an earlier stage among non-Hispanic women, while cancer among Hispanic women is established at a later time and stage. These observations may be mainly due to the beliefs and practices of Hispanics. It is been established that breast cancer is the leading cause of mortality among Hispanic women. In 2006 alone, almost 2,000 Hispanic women died from complications associated with cancer of the breast.

Theory Framework

The theoretical framework of the research conducted by Hall et al. (2007) was based on the premise that Hispanic women do not maximize the use of screening programs for breast cancer. The most common screening tool employed for breast cancer is mammography and this tool has detected thousands of malignant tumors among women around the world. On the other hand, Hispanic women do not avail of this screening tool and if ever they do present themselves for diagnostic screening, these individuals request such test at a late time wherein the tumor has already progressed to a stage that is often considered untreatable. Such observations have thus influenced the significant increase in the number of mortalities among Hispanic women with breast cancer.

Rosenstock et al. (1988) has proposed a possible explanation for such low usage of breast cancer screening tools is the Health Belief Model. This model system describes that the low turnout among Hispanic women for mammography and any other screening tool for breast cancer is greatly due to their inadequacy of knowledge of the importance of diagnostic tests in the detection of breast cancer. Research studies have earlier shown that there is a strong correlation between the amount of knowledge of these tools with the frequency of receiving and requesting such tests for the early prevention and ultimately, the detection of breast cancer. It is thus common to see that Hispanic women who strongly uphold classical Hispanic beliefs do not avail of the use and importance of breast cancer screening tools. This may be observed among Hispanic-Americans who were born and grew up in a Hispanic country and eventually migrated to the United States. These individuals carry the old beliefs that are respected and followed in their home countries, hence even if there are a significant number of locations around the United States that provide such sensitive screening tools such as mammograms, Hispanic women will not even think of taking such tests in their lifetime. However, among Hispanic women who were born in the United States and have acquired the culture of the Americans, availing breast cancer screening tools are generally a priority.

In order to test the Health Belief Model, the authors of the research article designed a research program that will address the issue that the beliefs and behavior of this specific group of women of particular ethnic origin strongly influence the relative rates, mortality and susceptibility to breast cancer. The issue of behavior also includes the confidence of Hispanic women in submitting themselves to the diagnostic clinic for breast cancer screening. The belief of an individual on a certain disease such as breast cancer also influences whether she will make an effort in determining whether she is free of the disease or whether the signs and symptoms that she observes during her daily life are clues that she has to act in order to get her self cured of the disease. Such seriousness on the issue of health thus also reflects whether an individual will let her cultural beliefs sway her actions or whether she will do something that will help her conquer such disease. In addition, the research also wanted to determine whether Hispanic women were confident in the breast cancer screening tools in helping them survive and live the rest of their lives in a disease-free state. The willingness of Hispanic women to get involved in activities that promote health was also addressed in the research.

Study Design

The study of Hall et al. (2007) was conducted with prior ethics approval for the corresponding review boards of the state of Arkansas. In addition, the subjects that participated in the interviews were guaranteed confidentiality and anonymity. It is also interesting to know that even the parish priest of the local church was asked for permission to conduct such study on the beliefs and perceptions of Hispanic women on breast cancer screening tools. The research is thus very careful not to insult or affect any aspect of the study population, wherein if an approval were needed to be procured from the religious body of the population, it will be availed.

Sample Selection

The inclusion criteria for the participants of the study were well classified because the subjects fit into the bases of the study. The participants were thus at least 18 years old, all female and positively admitted that they were of Hispanic origin. The recruitment was conducted through invitations published in newspapers that an educational program specific for breast cancer will be held at a specific time, date and venue. The research was also sensitive enough to adapt their project to the language barriers because they sent out their announcements in both English as well as Spanish so that all women may receive the information and possibly attend the educational program. In addition, as an incentive, the Hispanic women who attended the educational program were given free items such as lunch and door prizes. The research was also careful enough to employ an informed consent form for every participant that was included in the study.

Unfortunately, the study population of this research was not big enough to generate statistically significant numbers. The study population was only composed of 31 Hispanic women of varied ages, ranging from 25 to 56 years old. All of the participants resided within the northeast region of the state of Arkansas. The research followed a control group strategy that involved setting up of two groups composed of the 15 Hispanic women. The experimental group was subjected to an educational program on breast cancer and its associated screening tools, while the control group was subjected to an educational program on proper nutrition. The assignment of educational programs that each participant would attend was based on randomly picking out their names. This part of the experimental setup was good because this meant that a random method of selection was performed on the subjects and the participants themselves did not feel that each was separated intentionally based on their friendships. After the appropriate educational programs, the subjects were given questionnaires that asked their perceptions on breast cancer and the associated screening tools.

Measurement Tools

It is good to note that the research was conducted using three questionnaires that were translated into the Hispanic language in order to rule out any language barriers. One questionnaire contained questions regarding the demographics of the participants and the questions were constructed using sixth-grade degree of comprehension, to assure proper understanding by the participants. Another questionnaire involved the BCK test, which asked about the participants’ knowledge of breast cancer. The questions in this tool were constructed with consistency so that the participants can easily comprehend what was necessary to be completed. Thus, if a high score from the BCK test was attained for a participant, this high score meant that the participant understood the educational program that she attended. A third questionnaire follows the BCS test which involves the theory of the Health Belief Model, wherein a participant may respond to questions that reflect their perceptions on breast cancer. In addition, the questionnaire also included questions on the benefits of the breast cancer screening tools such as mammography and breast self-examination. The 5-point scoring system was employed in rating the answers of the BCS test. Most of the questions involved responses on whether the participant agreed or disagree with particular aspects of breast cancer and its associated screening tools.

Data Analysis

All the information gathered from the questionnaires was analyzed using the SPSS mathematical analysis software. The t-test statistical analysis was evaluated using the significance level of 0.05 and this is the correct test to perform before the intention of the research was to determine whether the education program on breast cancer and its associated screening tools influenced the way Hispanic women behaved.

Analysis of the information gathered from the 3 questionnaires that were given to the participants showed that the Hispanic women were more knowledgeable of the disease after attending the educational program that was provided. At the same time, the participants who attended the educational program on nutrition still did not understand the implications of breast cancer and its associated screening programs. These particular women thus still carried their old beliefs regarding breast cancer, such as this disease does not affect their particular ethnic group, as well as that they would rather not know if they have breast cancer. The same research also showed their perception that if a Hispanic woman is found to have breast cancer, she is not strong enough to be the mother of a family and that she is not fit to carry on in taking care of her household. It is thus encouraging to know that proper education of individuals helps in the understanding of breast cancer and their appreciation for the existence of breast cancer screening tools for the early diagnosis of breast cancer.

Confidence in the Study Findings

It is unfortunate to see that the sampling population of this research is not big enough to generate statistically significant conclusions. Their observations and conclusions could have been more reliable and credible if a bigger sampling population were employed, such as 500 Hispanic women or even more. In addition, it would also be better if a multi-center research were performed on Hispanic women, possibly including other Hispanic women from Texas, New Mexico and California. There may also be factors that affect the perceptions of Hispanic women regarding breast cancer. For example, if the research included Hispanic women in the northeastern states such as New York and New Jersey, maybe the results would show slight to significant variations because the educational background and occupations of these Hispanic women may be different, depending on the state where these Hispanic women live in.

It would also be interesting to see if these Hispanic women who were subjected to the educational program on breast cancer really followed what they learned after some duration of time. This strategy may facilitate in determining whether such type of intervention program were successful (Santacroce et al., 2004). For example, it would be good if the authors made a follow-up on members of both groups and checked if there were any changes in their perceptions on breast cancer. Another issue that may have helped the research conducted by Hall et al. (2007) was that there was no mention of any method for them to determine that status of their knowledge of breast cancer before the experimental educational program. This concern should be considered because there might be a chance that some of the Hispanic women in the experimental group may have pre-existing knowledge of breast cancer and its associated screening programs and that maybe these particular women did not learn anything from the breast cancer educational program provided during the experimentation and actually simply used their own knowledge of breast cancer during the completion of the questionnaires.

Consistency of this study’s findings with the findings from other studies

One factor that influences the low usage of breast cancer screening tools by Hispanic women is the notion that they see themselves as impermeable to any kind of disease, including breast cancer. Even when they see stories of breast cancer patients on the television or read accounts on magazines and newspapers, Hispanic women often perceive themselves as a unique ethnic group that is resistant to breast cancer. These Hispanic women think that these breast cancer stories that they observe around them can only affect the Caucasian women. Another perception that Hispanic women uphold regarding breast cancer is that this disease is untreatable hence once a women is positively diagnosed with breast cancer, she is destined to eventually die from it. Hispanic women are thus not properly informed that breast cancer, when diagnosed at an early stage, is treatable and that the patient may survive the disease.

Another misleading perception that Hispanic women uphold is that frequent physical injuries to the breast, including fondling and hitting, increases the risk of a women to breast cancer. In addition, Hispanic women also think that women is more likely to have breast cancer if she carries sexual relations with multiple partners. These false beliefs of Hispanic women have thus been kept for several years and this has influenced their appreciation of highly specific diagnostic tools for screening breast cancer. The religion beliefs of Hispanic women also influence their usage of breast cancer screening tools. Hispanics are generally Roman Catholic in religion and they believe that God has prepared a plan for them to live throughout their life, including any heartaches, obstacles and diseases that they encounter during their lives. Hence the occurrence of breast cancer in the life of a Hispanic women may be perceived as God’s holy will and they often times simply accept the occurrence and proceed on living with the rest of their lives without doing anything to treat the disease or to prevent the cancer from progressing.

One issue that may be of concern to this research article is the length of stay of each of the Hispanic women in the United States. It can be assumed that the longer the stay of an individual of a particular origin in her home country may be influence her beliefs as she now lives in the United States. For example, the beliefs of a Hispanic woman who has lived in the United States for 30 years may be different from the beliefs of a Hispanic woman who has only stayed in the United States for 3 years. In addition, the age of the Hispanic woman should also be considered because in relation to her immigration to the United States. This concern may be of importance because it is generally easier for a younger Hispanic female to imbibe Western beliefs once she moves into the United States than an older Hispanic woman.

It is also a belief among Hispanic women that there are certain topics that can not be talked about in public. Such taboo may including the topics of breast cancer because such disease is perceived to be rare among their ethnic group and if ever one of them succumbs to such disease, it must have been because the Hispanic woman has not followed the teachings and laws of God and thus she is being punished for her improper activities in terms of physical disease. In addition, Hispanic women would choose not to discuss the topic of breast cancer among discussion groups because such topic is very delicate and sensitive.

Hispanic women are also known to deny the truth, as well as shy away from instances that would provide details of their current condition. Hence Hispanic women would rather not know if they have breast cancer because it may cause them anguish, fear and depression. Thus Hispanic women would rather not subject themselves to breast cancer screening programs because they do not want to hear that they tested positive for breast cancer. They think that it is easier to live the rest of their lives not knowing that the dreadful disease is consuming their bodies. Such perceptions have thus largely influenced the number of Hispanic women who have availed of the breast cancer screening tools.

It is thus important that a bigger sampling population be used in these kinds of research. The condition of the state and the local city should also be taken into account. There are certain states and cities around the United States that have different concern for breast cancer. The highly developed and urban cities are generally more aware of such medical disorders, over the rural towns around the United States.

Readiness of findings for use in practice

I appreciate that the authors indicated that the word Hispanic does not pertain to a single population but actually a collection of individuals from different countries. With this in mind, different cultures may still be present in their small sampling population because some of the Hispanic women may come from Mexico while the other come from Guatemala or Argentina, which of course may also mean that they have different points of view with regards to breast cancer and other related issues. It should thus be taken into account that the word Hispanic is a term that pertains to a language that is inherently spoken, based on the Spanish language, but that does not automatically mean that the Hispanic women come from a single country of origin. With this in mind, it should be interesting to know what the observations would be if the authors conducted a research involving a bigger sampling population and they further segregated the participants with the precise country of origin.

Another factor that the paper of Hall et al. (2007) included a correlate to breast cancer mortality is the financial status of Hispanic women. Majority of these individuals are categorized in the low-income level hence any diagnostics tests that may be useful for breast cancer screening may be ignored because they would rather use their limited budget in spending for other more important expenses such as food and shelter. Most of the Hispanic women also do not carry any form of health insurance hence the cost of breast cancer screening tests can only be paid directly out of their pockets.

It is thus important that this study be repeated again at a bigger scale to check whether their initial observations remain the same or some variations could occur. It is very difficult to generate conclusions given the small size of the sampling population, yet I am aware that such goal of their research was to scientifically determine the perceptions of Hispanic women regarding breast cancer and the screening tools that are currently available. However, I would like to suggest that together with gathering information on the perceptions of these women of particular ethnic origin, I would also like to know the level of information that they have even before asking about their perceptions. It would thus be helpful if the authors included the distinction between perception and knowledge of an individual because there are some cases wherein even if an individual knows a certain issue or subject, the same individual also carries a different perception, regardless of his knowledge of that particular topic or issue.

Contribution of the Study to Nursing Knowledge

The research article of Hall et al. (2007) is a timely paper because it addresses the perceptions of Hispanic women on breast cancer. The paper may be helpful in understanding the factors that influence the behavior of these particular women, especially on deciding whether or not to avail of the services of breast cancer screening programs. The research paper would facilitate future intervention programs focused on breast cancer. The paper of Hall et al. (2007) is thus a timely paper that addresses whether Hispanic women are aware of the screening tools that are currently available for breast cancer. Aside from mammography, a woman may also perform breast self-examination for any lumps on her own breast. This simple test can be done alone and this may provide an initial observation that may help the medical professionals in conducting additional tests for validation of breast cancer. The paper was able to compile the information related to the perceptions of Hispanic women regarding breast cancer. It is quite alarming to read that most Hispanic women do not even know what mammography is. For those Hispanic that have heard of such word, they unfortunately do not understand and more so, appreciate the use of mammography in the detection of breast cancer. Improper understanding and worse, the lack of knowledge regarding early detection of breast cancer thus influences the mortality rate of Hispanic women to breast cancer.

References

Rosenstock, I.M., Strecher, V.J., & Becker, M.H. (1988). Social learning theory and the Health Belief Model. Health Education Quarterly, 15:175–183.

Hall, C.P., Hall, J.D., Pfriemer, J.T., Wimberley, P.D. and Jones, C.H. (2007). Effects of a culturally sensitive education program on the breast cancer knowledge and beliefs of Hispanic women. Oncology Nursing Forum, 34:1195-1202.

Santacroce, S.J., Maccarelli, L.M. and Grey, M. (2004). Intervention fidelity. Nursing Research, 53:63-66.